Medical Findings and Child Sexual Abuse

ABSTRACT: Physicians are increasingly being asked to conduct examinations
to determine if there is physical evidence that a child has been
sexually abused. Unfortunately, a common practice for many physicians
has been to form conclusions about abuse on the basis of vague physical findings
and In the absence of information outside of the fact that someone
believes the child has been abused. Recently, however, there has
been research on the characteristics of the genitals of normal,
nonabused children. This research provides the baseline
information needed to evaluate physical findings. This research is
described, the terms used in medical reports are defined, and the
physical findings which may be indicative of sexual abuse are discussed.

Up until a few years ago there was very little published in the
medical literature on the physical findings consistent with child sex
abuse. There was even less published on normal findings in
nonabused children.

Moreover, there were no extensive studies on what the hymen of the
nonabused child looks like. Some physicians claimed that the
normal hymen is circular and that any irregularity meant something had
been inserted into the vaginal canal. Although others maintained
that there is a wide variety of irregularities within the normal range,
they were unable to provide specific experimental data regarding the
frequency of these irregularities.

There was even controversy regarding the size of the normal hymenal
ring at various ages. Until recently, there were no extensive
studies in which measurements were taken. And even the studies
that were done were flawed by the fact that the investigators
failed to consider that the hymenal orifice varies in size with the
position the child assumes when the examination is being conducted, as
well as with the degree to which the child's legs are spread by the
examiner.

Similarly, there was no good information regarding the differences between
the normal anus and the anus that has been subjected to sexual
abuse. The necessary baseline studies had not been done.

In spite of this relative ignorance, physicians have been asked with
increasing frequency to provide the definitive "proof"
regarding whether or not sexual abuse has taken place. This has
been the case even though most people who are knowledgeable about child
sex abuse recognize that often there will be no physical findings
because the perpetrator has not done anything more than caress and
fondle the child. However, the need for such verification has been
strong, so strong that the objectivity of both those who make the
request and those physicians who have responded has been compromised.

In response to this need, pediatricians, pediatric gynecologists, and
people from other branches of medicine (such as internal medicine and
family practice) have become "experts" on child sex abuse in
recent years. Those who generally confirm sex abuse are attractive
to prosecutors, who can rely on them to provide the "definitive
medical evidence," that is, the "proof" that sex abuse
indeed took place. Those who rarely find sex abuse are likely to
be engaged by defense attorneys who invite them to testify that the
child is "normal" and that there was "no evidence for sex
abuse." Although there are people who claim that they are
completely neutral, my experience has been that most people who are
doing this kind of work have a reputation (whether warranted or not) for
being in either of the two camps.

There are doctors (even pediatricians) who claim that any inflammation
of a little girl's vulva is a manifestation of sex abuse. Most,
however, note that this is an extremely common finding and can result
from sweat, tight pants, certain kinds of soap, and the occasional mild
rubbing (sometimes masturbatory) activity of the normal girl.

There are some who maintain that the normal hymen is a perfect circle
(or close to it) without any irregularities. It follows, then,
that if any irregularities are found, these must have been artificially
created by the insertion of something, possibly a finger, possibly a
penis, or possibly something else (like a crayon or pencil). There
are others who claim that the normal hymen is most often not a circle
and there are irregularities, tags, and bumps. They believe that
these irregularities (sometimes referred to as serrated hymenal
orifices) are within the normal range of hymenal variation.

Some claim that a three-year-old girl's vagina can accommodate an
adult's fingers and even penis without necessarily showing signs of
physical trauma, other than the production of the aforementioned
irregularities, tags, and bumps. Others maintain that the
insertion of an adult male penis into a three-year-old girl's vagina
will produce severe pain, significant bleeding, and deep lacerations,
and that the insertion of crayons and pencils at that age is extremely
rare because of the pain and trauma that such insertion will produce.

There are significant differences of opinion regarding what is the
normal size of the hymenal opening, and this, of course, bears directly
on the question of abuse. Most experts agree that there have not
been large studies of many children at different ages with regard to
what the normal hymen looks like, its size, and whether or not it is
indeed circular. Furthermore, all agree that the older the child,
the greater the likelihood the vaginal opening will accommodate a penis
without significant trauma. Thus, by the age of nine or ten, one
does not get the same degree of trauma that is found at younger
ages. Most agree, as well, that children of nine and ten, whose
vaginal orifices are still small, could still be brought to the point of
intercourse with an adult by gradual stretching of the vagina in the
course of repeated experiences in which progressively larger objects
(fingers, and ultimately a penis) are inserted.

Some physicians believe that a certain type of dilatation
("winking") of the anal mucosa is pathognomonic of penile penetration
into the anus. There are others who claim that such dilatation is
normal. (Here I am with the group that holds that such puckering
is most often normal and is not a manifestation of sex abuse.)

The net result of this situation is that there may be sharply divided
opinions among physicians regarding whether a particular child has been
sexually abused. However, this does not stop each side from
bringing in a parade of adversary physicians who predictably provide the
"proof" that the child was sexually abused or that there is
"no evidence" of sexual abuse. Another result of this
situation is that many doctors are making a lot of money, because
providing court testimony can be quite remunerative.

Definition of Terms

I will focus here on several terms that are often seen in reports of
physical examinations of children being evaluated for sex abuse.
Because girls are much more frequently subjected to sex abuse than boys,
and because controversies regarding the signs of sex abuse are much
greater in girls than boys, most of these comments relate to the
physical examination of girls. It is assumed that the reader has a
basic familiarity with the female genitalia and is familiar with such
terms as labia majora, labia minora, clitoris, urethral meatus
(orifice), hymenal orifice, and vaginal walls.

Examination Positions

Most often there are two positions described for a girl's
examination, the supine frog-leg position and the prone knee-chest
position. When examined in the supine frog-leg position, the child
is on her back with her legs spread apart in "frog-leg"
fashion. In the prone knee-chest position, the child's abdomen is
close to the table and she is supported by her knees and chest.
McCann (1988) emphasizes the importance of the child's chest touching
the table and the child's back being in a relaxed position.
Examination of the vagina and cervix (without the use of a speculum) is
more easily accomplished in young children in the prone knee-chest
position. Sometimes a third position is utilized, the supine
knee-chest position. Here the child lies on her back, puts her
legs together, flexes her thighs at her hips, and is asked to hug her
knees to her chest.

Hymenal Configurations

There are a wide variety of hymenal orifices and
configurations. So great is their variation that some orifices do
not easily lend themselves into being categorized. Furthermore,
there is no strict standardization with regard to the names of the
various kinds of openings. Accordingly, different examiners may
use different names for the same hymenal configuration. The way in
which the child is positioned may affect the hymenal configuration and
thereby affect the name used by the examiner. I describe here the
most common types of vaginal orifices. Next to each name I have
placed in parentheses other terms that are often used for the same
configuration.

Annular (Circumferential, Cuff-like, Central) This is the
simplest configuration. The hymenal orifice is represented by a
relatively even circle. Basically, it is a circular hole that
can vary in diameter from almost a pinpoint to an enlarged orifice
that leaves practically no hymen at all, only a rim. The
cuff-like configuration is also annular, yet there is a thickening at
the circumference of the orifice. Most competent examiners agree
that the perfect circle type of hymen is not common.

Crescentic (Horseshoe, U-Shaped, Posterior Rim, Semilunar)
The hymenal orifice is represented by a half-moon or crescent.
The bottom of the U-shape, however, is at the posterior position (closest
to the anus). The hymenal tissue, then, can appear as if it were
hanging down from above (the anterior position).

Redundant (Denticular, Folded, Fimbriated, Serrated) Here
the configuration is one in which tooth-like (denticular) tags of
varying size project into the hymenal orifice. When these are
relatively small, they give a saw-tooth (serrated) appearance.
Because they are directed inward from the hymenal rim, they are called
fimbriated (fringed).

The redundant configuration is quite common. The hymenal
tissue projections are commonly referred to as tags and bumps.
Estrogen has the effect of thickening the hymen and increasing the
formation of these redundant projections into the hymenal
orifice. Accordingly, the prepubertal girl is likely to have
more such redundancies than younger girls. The spaces between
these projections are often referred to as notches and clefts.
These are to be differentiated from tears and lacerations,
which suggest the insertion (partial or complete) of some object
(animate or inanimate) beyond the hymen into the vaginal cavity.
Whereas notches and clefts do not extend outward to the base (or
periphery) of the hymen, tears and lacerations frequently do.
And this is one of the important differentiating criteria between
them. Furthermore, notches and clefts have rounded edges,
whereas tears and lacerations have sharp edges.

Vascularity of the tissue around notches and clefts is even,
smooth, and continuous with the vascularity and color of the rest of
the hymen. Just as estrogen increases redundancy, it also has
the effect of thickening the hymen and obscuring thereby the fine lacy
vascular pattern typical of younger girls. This thickening also results
in a loss of the translucency of the hymenal tissues, and the
thickening gives the appearance of rounding of the edge of the hymenal
membrane. Tears and lacerations are surrounded by tissue of
different color, depending upon the period between the trauma and the
time of the examination. The terms healed tears and scars are
used to refer to stages of healing. I will comment further on
these terms in the sections below.

Septate A septum is a partition or a dividing wall between
two spaces or cavities. A septate hymen with one or more
partitions (usually vertical) will result in two or more parallel (but
also vertical) orifices.

Slit-like The hymenal orifice is represented by a thin slit,
almost completely occluding communication between the vagina and the
exterior.

Punctate (Cribriform) In this configuration there are
multiple extremely small (pinpoint) orifices.

Imperforate Here there is no hymenal orifice at all.
This may not cause difficulties prior to puberty. After the
child stats menstruating, however, incision of the hymen is necessary
if there is to be proper release of the menstrual flow.

The term anterior is used to refer to that past of the hymen
that is closest to the front of the body, and the term posterior to that
part of the hymen that is closest to the back of the child's body.
Commonly, the site of a particular observation is described by
visualizing the hymenal ring to be like the face of a clock.
Accordingly, 12:00 o'clock would be the most anterior position; 3:00
o'clock the position closest to the child's left side (the examiner's
right); 6:00 o'clock, the position closest to the child's anus; and 9:00
o'clock the position closest to the child's right side (the examiner's
left). There is a widespread belief that attempts to insert an
object (animate or inanimate) into the child's vagina is more likely to
produce trauma to the posterior rim of the hymen, namely, in the range
from the 3:00 to 9:00 o'clock position.

Sometimes examination of the hymen may be compromised by the presence
of labial adhesions. These cause a sticking together of adjacent
parts of the labia minora. Sometimes the attachment is by fibrous
bands, and sometimes merely by a sticking together of labial
tissue. These are so common that they are generally considered to
be in the normal range. Most competent examiners would not
consider them, per se, to be a sign of sex abuse.

Additional Terms

Here I define further terms frequently seen in reports by examiners
assessing for sex abuse.

Labial adhesions This term refers to the "sticking
together" of the labia minora and/or labia majora. Other
names for the same phenomenon include labial agglutination, vulvar
fusion, vulvar synechiae, gynatresia, coalescence
of the labia minora, and occlusion of the vaginal vestibule.
Labial adhesions are usually seen between the ages of two months and
seven years. They are generally considered to be the result of
poor hygiene, a mild vulvitis, or mechanical irritation along with
hypoestrogenism (McCann, Voris, & Simon, 1988).

Synechiae This refers to a pathological union of
parts. It is synonymous with the word adhesion. It
is best viewed as a sticking together of parts that should be separate
from one another. Infection and irritation can cause synechiae.

Posterior fourchette A fold of mucous membrane just inside
the point of posterior conversion of the vulva (labia majora).

Examining Instruments

Because the hymenal structures are so small (the average normal
hymenal orifice of a three-year-old is 4-5 mm) and because measurements
may be difficult, variable, and somewhat subjective, visualization aids
are often used. One such aid is the traditional otoscope.
Although designed for examination of the ears, it has proven useful in
the genital examination as well. It is basically a flashlight with
a cone-shaped attachment and magnifying glass that, at the same time,
focuses a beam of light on the area to be examined and allows the
examiner to have a magnified view of what is being seen.

A superior instrument is the colposcope. The colposcope
is a pair of mounted binoculars which can be mounted on a tripod or
suspended from a movable mechanical arm. It generally magnifies
from 10 to 20 times. The colposcope allows for visualization of
structures that may not be visible to the naked eye. The
colposcope is also equipped with an internal light for better visualization.
It includes a green filter that assists in the examination of the
vascular bed. Finkel (1989) states: "The green light improves
visualization of scar tissue and alterations in the vascular pattern of
the hymenal membrane and perihymenal tissues." Special
cameras can be used to take photographs through the colposcope. The
terms colposcopy and colposcopic examination refer to the
procedure in which the colposcope is used. McCann (1990) has
written an excellent description of the colposcope and its use.
Muram and Elias (1989) have reservations about the colposcopy and do not
consider it significantly superior to the unaided eye.

The vaginal speculum is an instrument that allows for visualization
of the vaginal wall and the cervix. It is best visualized as a
split tube with a special handle. The tube is inserted into the
vagina and by squeezing the handle the tube expands, thereby widening
the vagina and allowing for visualization of the cervix and vaginal
wall, especially while the speculum is being removed. Although it
comes in various sizes, it is rarely used in the examination of
children. The insertion of a vaginal speculum into the vagina of a
child would be very painful, and even traumatic, especially to the
hymenal ring.

The Tanner Stages

The Tanner stages are used to describe objectively the developmental
level of the secondary sexual characteristics in children and
adults. The stage levels are divided into three categories:
breast, genitals, and pubic hair. For each of these there are five
or six stages, ranging from the most immature to the most mature. For
example, Stage I of pubic hair development is no pubic hair at
all. Stage II of breast development is the presence of a breast
bud, with elevation of the breast and nipple on a small mound.
Stage V of genital development in the male is a penis of adult size and
shape. Although the Tanner stage has little if anything to do with
sex abuse, the term is frequently seen in the medical reports of
children being evaluated for sex abuse.

The

Although the physical examination in cases of suspected sex abuse
will not be discussed in great detail here, there are some important
areas to consider in evaluating the significance of such an examination.

According to Muram (1989a), it is important for the examiner to
examine the child within one week of the alleged assault. It is in
that period that residual bruises and inflammation are more likely to be
present. Beyond that time these associated findings are likely to
disappear. The time between the alleged assault and the
examination should be noted in the report.

A common practice is for the physician who conducts the examination
to form conclusions about sex abuse purely on the basis of the physical
examination. The justification is that others should be
responsible for delving into the background information, which can shed
light on whether the sex abuse did indeed take place.

The doctor may claim, "I'm a doctor, not a detective. My
job is to describe medical findings; others concern themselves with the
investigation." I do not agree with this position. When
examining for the presence of other diseases, that same doctor would
certainly ask questions of one or both parents in order to obtain a
"history" and thereby get more information about the disease
under consideration.

Like most things in life, there is a continuum from the
zero-to-hundred level of involvement. A physician who only is
concerned with the physical examination is at the zero level in terms of
getting historical background information. Most physicians who
examine for sex abuse will go a little beyond that and get some
information from the party who brings the child, most often the
mother. Usually, such data collection does not occupy more than a
minute or two. Accordingly, there is little meaningful inquiry
into the details of the allegation and little opportunity to assess its
credibility and likelihood. I have never (I repeat never) seen a
medical report in which the examiner has seen fit to invite the alleged
perpetrator (even when the person accused is the father  the most
common case) to provide input.

Most often the examiner will state that the findings are
"consistent with sex abuse." However, I have seen
reports in which the alleged perpetrator is named, even though that
party was not only not seen but there wasn't even an invitation extended
to provide information. Such a practice is unconscionable and is
worthy, in my opinion, of a malpractice suit. Such a physician is
basically making a diagnosis on a person whom he or she has never
seen. I am certain that the same doctor would be very reluctant to
write any other diagnosis in a chart regarding a person who was not
directly examined.

The failure to get information from available alleged perpetrators
has caused much unnecessary grief. I cannot criticize such
physicians strongly enough. Although state laws generally require
the physician to report suspected abuse, they do not prevent the
physician from speaking with the alleged perpetrator before making a
final decision regarding whether a referral and investigation are
warranted. Furthermore, many of these physicians do not appreciate
the degree of ineptitude of the "validators" to whom they are
referring their patients. They seem to be operating under the
delusion that these people are competent in the area of differentiating
between true and false sex abuse accusations.

As physicians they are sworn to subscribe to the Hippocratic oath in
which they vow that they will "above all do no harm" to their
patients. There is no question that many of the children who are
referred to child protection services, evaluated by
"validators," and others of that ilk are being seriously
traumatized and that the physician has played a role in contributing to
such trauma. I am not suggesting that physicians break the
law. I am only suggesting that they take the time to get more
information before making such referrals. I am also pointing out
the common ineptitude of those people to whom they are referring their
patient for the "final decision."

Physicians must also appreciate how their "impressions" and
statements (for example, "consistent with sex abuse"),
although not conclusive in their minds, are interpreted by many lay
people as the final "proof." In many cases
"consistent with sexual abuse" becomes transformed into
"physical evidence of sexual abuse." Perhaps if
physicians appreciated this more, they would be less quick to come to
conclusions.

The measurement of the hymenal orifice is considered an important
part of the physical examination of girls suspected of being sexually
abused. It is important to appreciate how variable this finding
can be. It differs according to the examination technique used
(McCann, Voris, Simon, & Wells, 1990). Yet, there are people
who are in jail because of this one measurement. The horizontal
(transverse) diameter of the hymenal orifice is usually measured in the
supine frog-leg position. Many factors are operative in determining
what this diameter is. If the child is correctly positioned, the
heels will be placed just below the buttocks. Clearly, if they are
in another position, such as 12 inches below the buttocks, a different
measurement will be obtained.

The examiner must be sure that the child's heels are at the same
position assumed by those children on whom the normative data were
obtained. Then there is the variable of the degree to which the
child's legs are spread. Usually, an assistant stands next to the
child and slowly spreads the child's legs while distracting and
reassuring the child. Obviously, the greater the degree of spread,
the wider will be the hymenal orifice. However, even when the legs
are extended to the most extreme position that is comfortable, the labia
majora are usually still so close to one another that the hymen will not
be observable. Accordingly, the assistant generally pulls the
labia majora apart laterally and posteriorly in order to allow hymenal
visualization. Obviously, there are varying degrees of such
posterolateral traction, and the greater the traction, the greater the
expansion of the hymenal orifice. Therefore, the assistant must
attempt to apply such traction to the same degree applied by those
collecting the normative data. A common standard is for the
assistant to apply traction at the mid-point of the labia majora to a
point 1-1.5 cm on either side of the midline.

Furthermore, a lag must be allowed between the time of retraction and
the time of taking the measurement. There is usually a 1-2-second
period during which the hymenal ring must be allowed to dilate.
Competent examiners usually allow at least a 3-4-second time lag in
order to ensure that the hymenal ring is going to relax into its resting
position. McCann (1988) and McCann, Voris, Simon, & Wells
(1990) emphasize that the greater the traction on the labia majora, the
greater the width the hymenal diameter will be, and this is one of the
explanations for why different examiners get different results when
measuring hymenal openings. They also point out that the vertical
diameter is smaller in the supine frog-leg position than it is in the
prone knee-chest position.

A small millimeter ruler is then placed very close to the vaginal
opening. Obviously, any squirming by the child is going to
compromise the accuracy of this measurement. However, even under
optimum conditions, and even with strict reproduction of the positioning
used by those collecting the normative data, there is bound to be some
variability of measurement because of the minuteness of the measurement
being considered here. A millimeter is approximately 1/25 of an
inch. Although the human eye is capable of discriminating between,
let us say, 4 mm and 5 mm, it is obvious we are dealing here with a
discrimination that is close to the edge of the capability of the human
eye (and brain). One has to consider also that the distance of the
examiner's eye from the hymenal orifice and the distance of the ruler
from the hymenal orifice can very well affect the measurement perceived
by the examiner.

I am convinced that if the same examiner were to examine the same
child on the following day, even when attempting to reproduce exactly
the conditions of the examination, there would be variability.
Furthermore, another examiner, again under the same circumstances, is
also likely to come up with a different measurement. The American
Academy of Pediatrics (1991) in its statement, "Guidelines for the
Evaluation of Sexual Abuse of Children," emphasizes the
aforementioned variability and impresses upon pediatricians the
importance of taking these variations into consideration when making
decisions regarding the normality or abnormality of the size of the
hymenal orifice.

The prone knee-chest position is generally used to measure the
vertical diameter of the hymen. Here, too, lateral traction is
required if one is to properly visualize the hymen and there is great
variability regarding the child's positioning and the degree of lateral
traction. Again, standardization is necessary. McCann (1990)
states: "The head is turned to one side with the forearms resting
on either side of the head. The knees are separated 6-8 inches and
maintained in 90 degrees of flexion. The examiner's thumbs are
then placed beneath the leading edge of the gluteous maximus at the
level of the vaginal introitus and the posterior portion of the perineum
is lifted, revealing the hymenal orifice."

Obviously, the examiner who does not follow this procedure exactly
will obtain different measurements of the hymenal orifice.
Examination in the prone knee-chest position allows the hymenal tissues
to fall forward and thereby provides better visualization of the full
circumference of the hymenal orifice than is generally possible in the
frog-leg position. Horowitz (1987) provides a good general
statement of procedures for conducting a pediatric examination for sex
abuse, as does the American Academy of Pediatrics, Committee on Child
Abuse and Neglect (1991).

What are Normal Genital Medical Findings?

Female Genital Findings

As mentioned above, it has only been in recent years that extensive
studies have been done to determine normal genital findings in
children. This belated interest relates to the rapid increase in
reports of sex abuse and the need for accurate data in order to
differentiate the normal from the sexually abused child. It is my
hope that the reader will now be impressed with the complexity of the
problem of obtaining normative data with regard to the hymenal orifice,
and will be even more overwhelmed by the complexity of the problem after
a discussion of the wide variety of seemingly pathological
configurations that are found in normal children,

First, with regard to data collection on the size of the normal
hymenal orifice, one of the problems attendant to conducting such
studies is that of knowing with certainty that the children studied were
not abused. It is impossible to "prove" that
"something didn't happen." The greater the number of
children included in a study, the greater the likelihood the findings
will be credible. However, the greater the number of such child
subjects, the less the likelihood that each of them was studied in depth
with regard to whether or not they were sexually abused. The fact
that children were taken from a "normal population" of
youngsters who were not referred for abuse is no guarantee that some of
the subjects being studied were not abused. This is one of the
criticisms directed at such studies, especially by those who tend to
diagnose sex abuse in the vast majority of patients refereed to
them. These individuals are likely to use as criteria findings
that other observers would consider to be in the normal range.
This is one of the major problems in this field, and it is a significant
source of controversy.

Goff, Burke, Rickenback, and Buebendorf (1989) studied 273
prepubertal girls as part of their routine health assessment. They
measured horizontal diameters only in the supine knee-chest position and
the supine frog-leg position. No measurements were made in the
prone knee-chest position. The girls ranged in age from under age
1 to age 7. This study, as is true of most studies, confirmed that
the vaginal orifice increases in size with age. The authors found
that the horizontal hymenal diameter was generally larger when measured
in the supine knee-chest position than in the supine frog-leg
position. Interestingly, an orifice greater than 4 mm in
horizontal diameter was rare. The study is a very good one,
especially because the authors describe in great detail the exact
positioning of the children prior to measurement.

McCann, Wells, Simon, and Voris (1990) studied 93 girls between the
ages of 10 months and 10 years. Whereas Goff et al. (1989) used
direct visual measurements, McCann et al. (1990) used a
colposcope. McCann et al. took both vertical and horizontal
measurements in the supine position with labial separation, the supine
position with labial traction, and the prone knee-chest position.
McCann et al's findings are different from those of Goff et al., in that
the hymenal orifices were typically larger. There was only one
mean measurement below 4.0 mm, and that was the horizontal measurement
in the supine labial separation position, namely, 3.9 + 1.4 mm.
The largest finding was for the 8-year-old girls in the 8-l0-year group
in the prone knee-chest position, namely, the vertical diameter of
8.7+2.6 mm. Considering these extremes, one can see that the range
of the means goes from 3.9 to 8.7 mm.

Accordingly, physicians who believe that any measurement over 4 mm is
indicative of sex abuse (which would be suggested by Goff et al.'s
studies) would not find support in McCann et al.'s studies. Both
are competent examining teams and both have written articles that are
very impressive. Yet, they would be quoted by adversaries in a
courtroom dispute regarding whether or not sex abuse took place.

Finkel (1989) holds that a transverse hymenal diameter of greater
than 5 mm is suggestive of sexual abuse. However, because of the
unreliability of such measurements, repeated measurements must be taken
before coming to a conclusion. He also emphasizes that the
position of the child and the degree of relaxation are important factors
in determining the measurement.

Another reliable study was conducted by White, Ingram, and Lyna
(1989). Their subjects were 242 females, ages 1-12. Three
groups were studied: (1) sexually abused, (2) no history of sexual
contact, but at risk, (3) nonabused. Transverse diameters only
were obtained with patients in the supine frog-leg position.
Lateral tension was applied to the hymenal opening. Measurements
were made by visualization of a measuring tape held over the hymenal
orifice or by a cotton-tipped applicator. They found that 88% of
children who complained of penile/vaginal penetration had a vaginal
introital diameter of greater than 4 mm, as compared to 18% of children
who described no such penetration. They concluded that a vaginal
introital diameter of greater than 4 mm is highly associated with sexual
contact in children less than 13 years of age.

It is important to appreciate that the transverse diameter of the
average adult erect penis is approximately 3.5 cm (35 mm) and an index
finger is approximately 1.5 cm (15 mm) wide. Accordingly, the
insertion of either of these into a hymenal orifice of 5 mm will
invariably cause significant widening and, certainly in the younger
girl, pain and trauma. Accordingly, when a three-year-od girl
claims that an alleged perpetrator inserted his penis into her vagina
and the vaginal examination reveals a diameter of, for example, 7-8 mm,
it is extremely unlikely that the penetration being described actually
took place. The more likely explanation is either examiner error
or the hymenal orifice is at the upper end of the normal bell-shaped
curve of hymenal diameters.

McCann, Wells, Simon, and Voris (1990) describe other observations
relevant to the problem of differentiating the nonabused from the
sexually abused children. For example, some claim that rolled
hymenal edges are a manifestation of sex abuse. However, McCann et
al. found that the rolled edge is much more commonly seen in the supine
positions, but tends to disappear in the knee-chest position.
Finkel (1989), in contrast, states that rounded hymenal edges are one of
the results of the effects of estrogen in the prepubertal girl and are
more likely to be visualized in the knee-chest position. This not
only says something about the importance of positioning, but also says
something about rolled edges as a sign of sex abuse.

With regard to hymenal configuration, McCann et al. (1990) found
crescent (36%), concentric [annular] (32%), septate (1%), cribriform
(0%), imperforate (2%). In 17% of the subjects he was unable to
determine the exact configuration because of redundancy of hymenal
tissues and the failure of the hymenal orifice to open. These
findings lend confirmation to those who claim that a perfectly circular
hymen is not the only configuration. With regard to the hymenal
edge, he found the following: smooth (26%), irregular (25%), redundant
(25%), and angular (8%). Again, these findings lend support to
those who hold that there is great variation in the configuration of the
hymenal orifice. In the traction frog-leg position, with regard to
some of the "abnormalities" sometimes considered
manifestations of sex abuse, he found the following: thickened hymenal
edge (53.8%), localized roll of the hymenal edge (23.8%), hymenal mounds
(33.8%), hymenal projections (33.3%), hymenal tags (24.4%), peri-hymenal
bands (16%), septal remnants (8.6%), hymenal septa (2.5%), hymenal
notches (6.6%), hymenal synechiae [adhesion of the hymen to adjacent
tissues] (2.4%).

Some claim that the normal hymen is regular in its vascularity and
any areas of vascular irregularity, areas in which the vascularization
is different from surrounding tissues, is strongly suggestive of healed
tears and other signs of sex abuse. McCann et al. (1990) found
irregular vascularity in 31.3% of those children examined in the
separation frog-leg position, 30.9% in those children examined in the
traction frog-leg position, and 28.9% of those when examined in the
knee-chest position. Aside from areas of irregular vascularity,
they found areas of isolated increase in vascularity in 13.9% of those
examined in the separation frog-leg position, 16.0% of those examined in
the traction frog-leg position, and 22.8% of those examined in the prone
knee-chest position. These findings strongly suggest that the
vascular irregularity criterion for sex abuse is improper and risky
(especially for those being falsely accused).

The McCann et al. study directs itself, as well, to the frequency of
other "abnormalities" sometimes considered manifestations of
sex abuse. For example, he found labial adhesions to be present in
38.9% and periurethral bands in 50.6% of the children studied. He
found erythema of the vestibule to be present in 56% of the children
examined. (The vestibule is the portion of the vulva bounded by
the labia minora. At the floor of the vestibule are [from anterior
to posterior] the clitoris, urethral orifice, and the hymen.) As
mentioned previously, vulval rashes are quite common in children.
These relate to poor hygiene, a wide variety of infections (not
necessarily related to sexually transmitted diseases), tight panties,
certain soaps, rubbing, scratching, and masturbation (to mention the
most common). I have been involved in a number of cases in which
these more common and likely causes of the erythema were ignored and the
examiner concluded that the findings were "consistent" with
sex abuse or even manifestations of sex abuse.

I have discussed in some detail the McCann, Wells, Simon, and Voris
(1990) research because it provides compelling evidence that normal
children exhibit a wide variety of variations, many of which have been
considered signs of sex abuse. It is of interest that McCann et
al.'s original group consisted of 114 girls, but 23 were excluded
because of the early onset of puberty and the possibility of undetected
sexual abuse. The list of behavioral manifestations that warranted
their exclusion from the study included nightmares, fears, moodiness,
change in school performance, truancy, and acting out behaviors (among
others). All of these could be seen in normal children (at least
on occasion), and many of these behaviors are manifestations of a wide
variety of childhood problems completely unrelated to sex abuse.
There are sexually abused children, however, who may exhibit one or more
of these behavioral manifestations. To the best of my knowledge,
McCann et al. did not conduct a detailed inquiry regarding whether these
behavioral manifestations were signs and symptoms of sex abuse, were in
the normal range, or related to other causes. On the one hand, the
exclusion of all these children, simply on the basis of the presence of
one or more of these symptoms, made his sample "purer" 
thereby lessening the likelihood that sexually abused children were
included. On the other hand, he may have unnecessarily shrunk his
patient population, thereby lessening somewhat the credibility of his
findings and depriving himself of many subjects who were not molested.

Anal Findings (Male and Female)

Anal and perianal findings are also a source of significant
controversy. One of the most widely known such controversies
relates to the anal examinations described by Hobbs and Wynne (1986,
1987). These examiners claim that a pathognomonic sign of child
sex abuse is "reflex dilatation and alternate contraction and
relaxation of the anal sphincter or 'twitchiness' without
dilatation." One finding, also referred to as anal
"winking," is considered a pathognomonic sign of anal intercourse.
As a result of using this criterion, hundreds of children in England
were diagnosed as having been sexually abused, with the result that 121
children were removed from 57 families. It took a government
investigation to bring society to its senses and return these children
to their families.

McCann, Voris, Simon, and Wells (1989) studied 267 children (161
girls and 106 boys), ages 2 months to 11 years. They found anal
dilatation in 49% of the children, and the mean time of the initial
dilatation was 65 seconds. The anus opened and closed
intermittently in 62% of the subjects in which dilatation
occurred. Accordingly, about 30% of all the children studied
exhibited the intermittent dilatation and relaxation of the anal
sphincter, which Hobbs and Wynne considered a sign of sex abuse.

McCann et al. (1989) describe other anal findings in normal children
that are often considered signs of sex abuse. They found that 41%
of their group exhibited erythema. There is no question that
children who have been sexually molested per anus will exhibit
erythema. But in this study, 41% of normal children exhibited
erythema as well. McCann et al. found increased pigmentation in
30%, another finding that is often considered a sign of sex abuse.
They found venous engorgement in 52% after two minutes in the knee-chest
position. Again, venous engorgement has also been considered a
sign of sex abuse. Anal tags and folds are also considered by some
to be indicative of sex abuse. These were found anterior to the
anus in 11% of the children studied. No abrasions, hematomas, or
fissures (common findings in sex abuse) were found.

What are the Genital Findings in Sexually Abused Children?

Studies of the anogenital findings in sex abuse are beset by a number
of problems. First, all knowledgeable investigators agree that
some children who have been genuinely abused sexually will exhibit no
medical findings. This relates to the fact that they were caressed
and touched in a way that would not be expected to cause physical
trauma. Another problem relates to the fact that the investigators
can never be sure that all the children in the nonabused group studied
were indeed never abused. There is also the risk that some of the
children in the abused group were indeed not abused, but this is less
likely. A third problem relates to the fact that a wide variety of
abnormalities are seen in normal children, and the aforementioned
studies of McCann and his colleagues provide good verification of
this. What we are trying to find, then, are specific
medical findings that are seen only in abused children and not in those
who have not been abused.

Female Genital Findings

Emans, Woods, and Flagg (1987) studied 305 girls. They were
divided into three groups: (1) sexually abused (119 girls), (2) normal
girls with no genital complaints (127 girls), and (3) girls with other
genital complaints (59 girls). The abused group was more likely to
have scars on the hymen or the posterior fourchette (9% vs. 1%, p <
0.002), increased friability (ease of bleeding) of the posterior
fourchette (10% vs. 1%, p < 0.001), attenuation (stretching and
thinning) of the hymen (18% vs. 4%, p < 0.0003), and synechiae
(adhesions) from the hymenal ring to the vagina (8% vs. 0%, p <
0.0009). We see here that we are not dealing with a situation in
which a finding is present in the abused group and not present in the
nonabused. Rather, certain findings are more likely to be present
in the abused group than in the nonabused group. The obvious
problem with this kind of finding is that its presence then does not
necessarily mean that the particular child being examined was abused.

Interestingly, Emans et al. (1987) found a wide variety of symptoms
to be present with equal likelihood in the abused group and the
nonabused group with other genital complaints. There was no
statistical difference between groups 1 and 3 regarding the frequency of
abrasions, hymenal tears, intravaginal synechiae, and condyloma
acuminata (venereal warts). This study, then, suggests that these
particular findings are not of diagnostic significance when attempting
to differentiate abused from nonabused children. Interestingly,
erythema (reddening) was more common in the nonabused group than in the
abused group (68% vs. 34%, p < 0.0001). There was no
statistical difference between the dimensions of the hymenal opening of
the abused and the nonabused group. One would certainly expect a
larger average hymenal opening in the abused group, but this study did
not confirm such a difference. Perhaps there were too few girls in
the 119 abused who had the kind of sexual molestation that would produce
an enlargement of the hymenal ring. However, as Herman-Giddens and
Frothingham (1987) point out, "The hymen, contrary to common
notion, is often a slack, thick, folded, stretchable tissue which may
persist after digital or penile penetration." The same
authors hold that "a vaginal opening of greater than 5 mm is not
common and may indicate vaginal penetration with a finger, object, or
penis."

McCann (1988) states that 85% of preadolescent children who are being
molested are molested on a chronic, ongoing, and recurring basis.
Such molestation should, then, produce changes indicative of chronic trauma.
He emphasizes the importance of examination for bruises in other
parts of the body, in the nongenital area. The mouth is a common
site of lesions because the perpetrator may have placed his hand over
the child's mouth in order to stop the child from screaming. Grab
marks on the arms and inner thighs are also strongly suggestive of sex
abuse, especially thumb marks on the inner aspect of the thigh, placed
there when the child's legs were forced apart.

McCann (1988) also observes that labial injury is common at the time
of rape because the labia majora are generally closed and the
perpetrator pushes his penis repeatedly against closed labia. He
believes that the most common area of hymenal injury is between the 4:00
and 7:00 o'clock positions because the penis is forced downward and
backward. He emphasizes that children heal quickly and that
examinations after the first few days may not confirm the abuse.
Because the length of the vagina of four- and five-year-old girls is
only 4 cm, trauma to the vagina, cervix, and lower part of the uterus is
common.

McCann, Voris, and Simon (1988) studied six sisters, all of whom had
been sexually molested by male family members. All of these girls
had labial adhesions, and four of the six had changes in the area of the
posterior fourchette (a fold of mucus membrane just inside the posterior
commissure of the vulva). Furthermore, four of the girls' hymens
revealed abnormalities of the hymenal edge (irregular, rolled, or
septum) and three revealed irregularities of the hymenal membrane
(redundant, thick, scarred). Four exhibited abnormal vascular
patterns, and all six exhibited adhesions and/or scars of the posterior
fourchette. The labial adhesions in these cases were associated
with posterior fourchette changes and other findings consistent with sex
abuse. The authors' position is that labial adhesions per se are
not indicative of sex abuse. However, if associated with other
findings suggestive of sex abuse, such as posterior fourchette trauma,
then it should be considered one such manifestation. We see here,
then, a situation in which a normal finding is considered a sign of sex
abuse under certain circumstances. In these six cases the labial
adhesions were associated with other findings indicative of sex
abuse. Furthermore, labial adhesions usually occur from ages two
to seven. In this case two of the girls were ages eight and nine,
beyond the age at which one usually sees labial adhesions.

Muram (1989a) divides the genital findings into four categories:

1.

Normal-appearing genitalia.

2.

Nonspecific findings. Abnormalities of
the genitalia that could have been caused by sexual abuse, but
also are often seen in girls who are not victims of sexual
abuse (e.g., inflammation and scratching). These
findings may be the sequelae of poor perineal hygiene or
nonspecific infection. Included in this category are
redness of the external genitalia, increased vascular pattern
of the vestibular and labial mucosa, presence of purulent
discharge from the vagina, small skin fissures or lacerations
in the area of the posterior fourchette, and agglutination of
the labia minora.

3.

Specific findings. The presence of one
or more abnormalities strongly suggesting sexual abuse.
Such findings include recent or healed lacerations of the
hymen and vaginal mucosa, enlarged hymenal opening of 1 cm,
proctoepisiotomy (a laceration of the vaginal mucosa extending
through the rectovaginal septum to involve the rectal mucosa),
and indentations in the skin indicating teeth (bite)
marks. This category also includes patients with
laboratory confirmation of a venereal disease.

4.

Definitive findings. Any presence of
sperm.

It is of interest that Muram (1989a) considers labial agglutination
to be a nonspecific finding, in that it does not necessarily indicate
sex abuse. Of importance in the third category, specific findings,
are hymenal tears that extend to the base of the hymenal ring as to be
differentiated from hymenal clefts which do not extend that
peripherally.

Muram believes that an astute examiner will do just as well with the
unaided eye as with the colposcope. Muram (1989b) studied 31 girls
who were assaulted by 30 individuals, all of whom confessed to having
sexually molested them. Both the girls and the perpetrators were
in agreement that the sex abuse took place. Obviously, this is a
good study sample for ascertaining the physical effects of sex
abuse. It circumvents one of the aforementioned problems regarding
such studies, namely, the uncertainty regarding whether or not the girl
being examined was genuinely abused or was genuinely in the nonabused
category.

In 18 of the 31 cases the offender admitted to vaginal
penetration. However, specific findings were only to be found in
11 of these 18 girls (61%). In those girls in which penetration
was denied only 3 of 13 (23%) provided specific findings. However,
the girls ranged in age from 2 to 15, so it is not surprising that some
of the teenagers who experienced penile penetration did not have
physical findings of abuse.

It is of Interest that of the 31 girls, inflammation, bruising, and
irritation were seen in only 9, all of whom were evaluated within one
week of the assault. None of the girls evaluated one week after
the abuse had findings suggestive of inflammation. Muram states:
"If no tear of the hymen occurred, the examination will fail to
detect any abnormalities." This is an important point. According
to Muram, the most important specific sign of sexual molestation Is
hymenal tear, to the base, especially extending into the vaginal
canal. Other abnormalities, such as inflammation and bruising,
tend to heal within a week.

The most important observation Muram makes is that the most
consistent finding in bona fide sex abuse is laceration or tear of the
hymenal ring, down through the base, and extending often into the
adjacent vaginal wall. This sign is one of the most important for
differentiating genuine from fabricated abuse.

On occasion, a child may sustain significant genital injuries
associated with trauma to the perineal area as a result of falls and
fence or straddle injuries (Behrman & Vaughn, 1983; Paul,
1986). Here one may see the kinds of lacerations seen in sexual
abuse. One may also see abrasions and other forms of injury to the
perivaginal area. However, the time of the trauma is generally
well known to the child (and usually an adult), and there is nothing
else in the history to suggest sexual abuse. Paul (1977, 1986)
claims that penile penetration in younger children will cause widespread
injuries, including lacerations of the hymen, vagina, and labia.
There will be profuse bleeding and the child will experience excruciating
pain. This is an important point because in many cases of
fabricated sex abuse, the child will describe no pain or minimal pain.

Anal Findings

McCann (1988) observes that children who have been subjected to anal
intercourse on repeated occasions suffer with a relaxation of the
external anal sphincter, but not of the internal anal sphincter.
Accordingly, there is a typical funnel-like appearance of the anus on
physical examination.

Finkel (1989) reports on seven children who had experienced acute
genital and anal trauma in association with sexual abuse. Some of
the more superficial manifestations of the trauma (abrasions,
superficial lacerations, contusions, and bleeding) were not apparent
after four days. In two of Finkel's seven cases, penile-anal
penetration was involved. In one case, Finkel described
"superficial lacerations of the anal verge tissues in anterior and
posterior midline positions each measuring 2 mm circumferentially and 3
mm in length." In the second case he described five
mucocutaneous superficial lacerations, some of which extended from the
external anal mucosa down into the anal canal.

Paul (1990) observes that, even with the use of a lubricant, penile
penetration of the anus will almost invariably result in some injury to
the anal verge. He stresses the importance of the history, from
the child, of severe pain  not only during the abuse, but when the
child next attempts to have a bowel movement. He states: "This exacerbation
of pain on defecation is an almost invariable 'story' and is so
impressed on the child's mind that it is rarely forgotten" (p. 6).

Sexually Transmitted Diseases

The presence of a sexually transmitted disease (previously referred
to as venereal disease) is generally considered definitive evidence for
sex abuse. Of the wide variety of such diseases, the most commonly
found in sexually abused children are gonorrhea, syphilis, Chlamydia,
condyloma acuminatum, Trichomonas vaginalis, and herpes 1
(genital). However, it is important to appreciate that gonorrhea,
syphilis, and Chlamydia can be acquired perinatally from the mother, and
this must be given consideration before deciding that the presence of
such a disease automatically indicates sex abuse (American Academy of
Pediatrics, Committee of Child Abuse and Neglect, 1991).

The material for gonorrhea culture is generally obtained from cotton
swabs of the vagina, throat, and rectum. The organism may
sometimes be grown from cultures of the urine of suspected boys.
The urine can also be examined for Trichomonas infection. Tests
for syphilis are usually obtained from a blood sample. Vaginal
secretions can also be cultured for the presence of Chlamydia, herpes,
and Trichomonas. Vaginal secretions can be examined directly
(microscopically, with proper staining) for gonorrhea and Trichomonas.

Condyloma acuminatum is also referred to as genital warts and
venereal warts. It is caused by a virus called the human papilloma
virus (HPV). It is the most common viral sexually
transmitted disease in the United States and is now more common than
herpes (due to the recent rapid increase in its incidence).
Because the incubation period is approximately one month (Stewart,
Stewart, Guest, & Hatcher, 1987), the genital warts will not be
observable immediately after a child has been abused. The
diagnosis is made generally by direct observation, the warts usually
appearing like warts on other parts of the body, but they do extend into
the vaginal canal, cervix, and rectum. Sometimes the warts are
inconspicuous or completely invisible to the naked eye. Horowitz
(1987) provides an excellent protocol for the examination for sexually
transmitted diseases.

Although the presence of a sexually transmitted disease is strongly
suggestive of sex abuse, the disease may have been acquired by the child
in a nonsexual way. The problem in such situations is that the
suspect may also have the sexually transmitted disease but did not have
a sexual encounter with the child. Rather, the disease was
transmitted nonsexually. Clearly, an accused who is trying to deny
a sexual encounter will give strong support to this theory.

Support for this can be found in the medical literature, where there
are many articles providing instances of just such a method of transmission.
For example, Shore and Winklestein (1971) claim that 50% of their sample
of children contracted their gonococcal infection in the absence of sex
abuse and that only one-fifth acquired the gonorrhea through a sexual
experience. Kaplan (1986) claims that the gonococcus can survive
outside the human body for up to 24 hours and cites a 1929 study in
which several newborns in the same hospital nursery were found to have
gonococcal infections. It was believed that the organism was
transferred with thermometers. Wakefield and Underwager (1988)
refer to studies in which gonorrhea was found to have been transmitted
nonsexually among peers, via close physical contact with infected adults
or indirect contact through bedclothes or hands. They also refer
to the work of DeJong et al. (1982), who report that venereal warts can
be transmitted through close nonsexual contact, during delivery, and by
sexual encounters.

Sperm in the Vagina and the Pregnancy Test

The presence of sperm in the vagina of a prepubertal child is obvious
evidence for sex abuse. It is proof that a postpubertal male has
sexually penetrated the prepubertal girl. The presence of sperm in
the vagina of a postpubertal girl is not necessarily evidence of sex
abuse, in that she may have voluntarily had sexual relations without in
any way being abused.

Fresh sperm can be examined directly under the microscope.
After 24 hours sperm may not be viable enough for such direct examination.
Sperm may be visualized with Wood's light, under which it becomes
fluorescent. These fluorescent "tear drops" shine
dramatically in contrast to other vaginal secretions that are examined
under Wood's light (McCann, 1988). The examiner must take care to question
the parents regarding whether the child has taken a bath between the
time of the alleged abuse and the time of the examination.
Obviously, if the sperm has been washed out, the Wood's light test will
not be positive. The sperm sample can also be tested for the
presence of acid phosphatase, an enzyme that is secreted by the prostate
gland and is to be found in the ejaculate. Acid phosphatase is not
normally found in the vagina.

In association with the examination for sperm, one must consider the
pregnancy test. Obviously, the pregnancy test is not viable for
prepubertal children, although there are reports of pregnancy in girls
as young as eight and many examiners will routinely do them for children
of that age and above. Although conducting a pregnancy test on a
prepubertal child may seem unnecessary and even absurd, it is not
completely so. There are children who are capable of becoming
pregnant who have exhibited few, if any, signs of sexual maturity.
And this is where the Tanner level of sexual development may provide
information regarding whether or not the child could indeed be pregnant.
An eight- or nine-year-old, exhibiting Tanner II and III levels, may
very well be capable of pregnancy.

Conclusions

Although physicians have been performing medical examinations and
drawing conclusions about sex abuse, their conclusions have often been
ill-considered and unsupported by empirical data. The recent research
on the characteristics of the genitals of normal, nonabused children
provides the baseline information needed to evaluate physical
findings. This research indicates that many of the physical
findings often claimed to indicate probable sexual abuse are found
frequently in nonabused children. This research must be taken into
account when evaluating reports of medical examinations of children in
cases of suspected sex abuse.